your elderly patient has a temperature of 985 degrees is there anything else that a nurse should do in addition to documenting this temperature

NCLEX-RN

NCLEX RN Exam Prep

1. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

A. No, this temperature is within normal limits.
B. No, this temperature is normally hyperthermic.
C. Yes, this temperature is highly hyperthermic.
D. Yes, this temperature is highly hypothermic.

Correct answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

2. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

A. Wait 30 minutes if the patient has ingested hot or iced liquids.
B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
C. Shake the glass thermometer down to 35.5�C before taking the patient's temperature.
D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5�C, not 37.5�C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer. Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.

3. When examining an older adult, which technique should the nurse use?

A. Minimize touching the patient as much as possible.
B. Attempt to perform the entire physical examination during one visit.
C. Speak loudly and slowly due to potential hearing deficits in aging adults.
D. Arrange the sequence of the examination to allow as few position changes as possible.

Correct answer: D

Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.

4. Each small square on the EKG paper is:

A. 0.04 seconds long and 5mm tall
B. 0.2 seconds long and 5mm tall
C. 0.04 seconds long and 20mm tall
D. 0.04 seconds long and 1mm tall

Correct answer: D

Rationale: Each small square on an EKG paper represents 0.04 seconds long and 1mm tall. This standardization is essential for accurate measurements. One large square on EKG paper consists of 5 small squares in length and 5 small squares in height, which equals 0.2 seconds long and 5mm tall (0.5 mV). Choice A is incorrect because while the duration is correct, the height mentioned is not accurate. Choice B is incorrect as it provides the correct height but the duration is inaccurate. Choice C is incorrect as the height mentioned is exaggerated, and the duration is correct but the height is not. Therefore, the correct answer is 0.04 seconds long and 1mm tall.

5. Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?

A. Sports and games with rules.
B. Finger paints and water play.
C. "Dress-up"? clothes and props.
D. Chess and television programs

Correct answer: A

Rationale: For 7-year-old children, play serves an important role in developing cooperation, logical reasoning, and social skills. Organizing sports and games with rules is beneficial as it helps children understand the importance of rules, promotes teamwork, and fosters social interactions. Finger paints and water play, while fun, may not target the specific developmental needs of this age group. Similarly, 'Dress-up' clothes and props can encourage imaginative play but may not necessarily promote cooperation and logical reasoning. Chess and television programs are more suited for older children and may not engage 7-year-olds as effectively in developing the desired skills.